Maryland picks model for essential health insurance benefits

Andrea K. Walker, The Baltimore Sun

Under national health care reform, insurance policies in Maryland will be required to cover acupuncture for pain management and chiropractic care in certain cases.

The plans won't cover acupuncture for other treatments, such as infertility or stress, and will limit home health care to 120 visits per year and physical therapy for ailments such as sports injuries to 50 days a year.

The state panel charged with implementing health care reform in Maryland voted Thursday to include these services among those insurers will be required to cover once reform is fully implemented in 2014.

The Affordable Care Act requires that insurers cover certain "essential benefits" but leaves the details up to the states, which must choose from 10 insurance options already sold within their borders. Plans could look different from state to state. Some may cover chiropractors, while others may not.

The Maryland Health Care Reform Coordinating Council chose to model insurance policies under reform after the plans currently offered to the state's employees. The 16-member panel reviewed 10 insurance options before choosing the state plan.

The state plan didn't offer the best coverage in all areas, the group said, butit struck a good balance between offering comprehensive coverage and not driving up costs for consumers.

Panel members said the plan must not be so costly that it dissuades people from opting in. People can choose not to buy insurance, but will have to pay a penalty. In order for reform to work, a balanced share of healthy and sickly people need to be enrolled to share in the costs.

"This plan will give meaningful coverage, but it will still be affordable," said Carolyn A. Quattrocki, the coordinating council's executive director.

Insurance companies don't have to model their plans exactly after the state plan, but they must offer similar options. Open enrollment on the health exchange, the marketplace where those without employee-sponsored insurance will be able to buy policies, will begin in October 2013. Reform will be instituted three months later.

"This gives a green light for insurers to start designing plans for January 2014," said state Health Secretary Joshua Sharfstein, who co-chairs the coordinating council with Lt. Gov. Anthony Brown.

As a baseline for comparing premium costs, the panel used a small-group plan used by small businesses and an HMO offered in the state. The state plan proved more costly than those and the federal plans the panel considered because it offers in-vitro fertilization and other benefits not offered by the federal plans.

The state employee plan costs between $1.50 and $2 more per member each month than the small-group and HMO plans. The least expensive federal plan cost $4.50 less than those plans.

The panel felt the lower-cost plans didn't offer enough coverage and that the difference in price between the plans wasn't that significant. Other factors, such as any co-payments and deductibles patients must pay out-of-pocket, also will influence costs.

The 10 plans the panel considered were similar when it came to basic coverage but differed in specialty categories. The plans covered ambulatory services, chemotherapy and prenatal care, for example. Yet speech therapy was limited to 30 days a year under the HMO, 50 days a year under the state plan and 75 under a standard federal health plan. Hearing aids for adults are not covered under the state plan or HMO but a standard federal plan provides up to $1,250 per ear every three years.

The panel also voted Thursday to include pediatric dental and vision care among the requirements for insurance plans under reform.

There was some debate among panel members about whether in vitro fertilization should be covered. The panel voted to allow insurers to substitute other services of similar costs instead of in vitro fertilization if they wished.

The federal government has yet to set standards on substituting services in plans, but the coordinating council said the Maryland Insurance Administration could write regulations for that process.

State officials estimate that one-third of Maryland's 750,000 uninsured residents will gain coverage under reform in its first year. Those living on less than 133 percent of the federally established poverty level — about $31,000 for a family of four — also will gain coverage through an expansion of Medicaid.